Health inspection·April 16, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observations during a tour of the dry storage room was conducted with the Director of Nursing on April 16, 2024, at approximately 11:30 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, was identified: The door to the dry storage room was open. A 5 lb. bag of chicken bread coating and a 25 lb. bag of flour were opened, and no date was noted when they were opened and put into use. The packages were not closed securely, simply loosely folded closed at the opening at the top of each bag, failing to fully protect the contents. A ziplock plastic bag, containing an opened package of walnuts was observed in a brown box on a metal shelf. The brown box also contained another bag of opened walnuts and loose walnuts were observed in the bottom of the box. The baseboard molding running along the bottom of the wall of dry storage room, beneath the metal shelving unit on the right-hand side of the room was missing, exposing dry wall and approximately a ½ inch gap was observed between the wall and the floor. A glue trap and mouse droppings were observed along the same wall. The dry storage room is located next to the kitchen. Observation of the kitchen revealed a grey and orange personal backpack on the metal kitchen counter next to the toaster and below the kitchen knives mounted on the wall. Observations of the kitchen and dry storage room were confirmed with the facility's Certified Dietary Manager on April 16, 2024, at approximately 11:45 AM. Interview with the Director of Nursing on April 16, 2024, at approximately 12:30 PM, confirmed that the kitchen and all food storage areas should kept in a sanitary manner and all foods and beverages should be stored in a safe and sanitary manner. Refer F925 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395905 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395905 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Third Avenue Health & Rehab Center 702 Third Avenue Kingston, PA 18704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 28 Pa. Code 201.18 (e) (2.1) Management Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.6 (f) Dietary Services Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395905 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395905 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Third Avenue Health & Rehab Center 702 Third Avenue Kingston, PA 18704 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews with resident sand staff, it was determined that the facility failed to maintain an effective pest control program. Residents Affected - Many Findings include: Observations during an environmental tour of the facility on April 16, 2024, at approximately 11:30 AM, down the service entrance hallway in the presence of the Director of Nursing, revealed that the doors to the kitchen, dry storage room, and mechanical room were open. Further observation revealed that the door from the mechanical room leading to the outside of the building was also open to the outside, providing a means of entry for pests. Observation of the dietary dry storage room revealed that there were mice droppings on the floor and on a pest glue trap located beneath a metal shelving unit on the right-hand side of the room. The facility's pest control company invoice/report dated March 6, 2024, failed to include information related to services provided and/or results of any inspection. Review of the facility's pest control company invoice/report dated April 3, 2024, indicated that service to all rooms and restrooms, service to kitchen and dining room, check all rooms for mice, and rebait exterior bait stations was completed. The report did not identify the outcome of the checks and bait stations related to presence of rodent/mice activity. Interview with the Director of Nursing on April 16, 2024, at approximately 12 PM confirmed the presence of rodent activity in the facility, as evidenced by by mice droppings in the facility's dietary dry goods storage room, and that the reports from the pest control company were limited in information regarding pest activity and recommendations for the facility to employ to deter and eliminate the pest activity. Refer F812 28 Pa. Code 201.18 (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395905 If continuation sheet Page 4 of 4